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TREATMENT of HYPERTENSION in DIALYSED PATIENTS Cilazapril R(H) 25 % YES István Kiss, Department of Nephrology-Hypertension, St

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TREATMENT of HYPERTENSION in DIALYSED PATIENTS Cilazapril R(H) 25 % YES István Kiss, Department of Nephrology-Hypertension, St "Elimination, "Supplement required Appendix continued... Dosing Miscellaneous Metabolism" with dialysis" Anemia, anaphylactoid ACE inhibitors reactions Non-renal clearance of 2004; 5: No. 21 Benazepril R(H) 50 % NO benazeprilate Active metabolite Captopril R 25-50% YES accumulation TREATMENT OF HYPERTENSION IN DIALYSED PATIENTS Cilazapril R(H) 25 % YES István Kiss, Department of Nephrology-Hypertension, St. Imre Teaching Hospital, Csaba Farsang, 1st Department Enalapril R(H) 50 % YES Patent drug accumulation of Internal Medicine, Semmelweis University Medical Faculty, Budapest, Hungary, and Jose L. Rodicio, Department Fosinopril R and H Unchanged NO 50% hepatic elimination of Nephrology, Hospital 12 de Octubre, Madrid, Spain Lisinopril R 25 % YES Perindopril R(H) 25-50% YES Quinapril R(H) 25-50% NO Introduction medication. The reasonable target goal of a mean ambulatory blood Hypertension is common in dialysed patients (>80% at pre-dialysis pressure is less than 135/85 mmHg during the day and is less than Ramipril R(H) 25-50% YES state, >60% in patients with hemodialysis, >30 percent in those with 120/80 mmHg by night (4). Very low systolic blood pressure (<110 mm Trandolaprilate is further peritoneal dialysis) (1). The leading cause of death in dialysed patients Hg) may be associated with enhanced cardiovascular mortality (“J” or Trandolapril R(H) 50 % YES metabolized prior to excretion is cardiovascular. “U” shaped curve). An algorithm for blood pressure control is given in Angiotensin II receptor The relationship between hypertension and cardiovascular Table 2. antagonists mortality/morbidity is apparently controversial in dialysed patients because of the high prevalence of co-morbid conditions, by the under- Table 2. Algorithm for blood pressure control in dialysis patients Candesartan R (H) AVOID lying vascular pathology and by the effects of dialysis on blood pres- (modified from ref. 8) _________________________________________________ Eprosartan H AVOID sure. The effects of age, left ventricular hypertrophy/dysfunction (also more prevalent in patients with hypertension) and poor nutrition may 1. Estimate dry weight Irbesartan H Unchanged NO mask the true relationship between blood pressure and mortality in 2. Determine Hypertension Severity Index Losartan R (H) Unchanged NO dialysed patients (2). Hypertension has been associated with stroke, 3. Initiate non-pharmacological treatment Olmesartan R H Unchanged NO ventricular arrhythmias and progression of atherosclerosis in patients 4. Attain dry weight on hemodialysis. Improved survival due to adequate blood pressure 5. Start or increase the dose of antihypertensives to maintain BP Telmisartan H Unchanged NO control of dialysed patients has been clearly demonstrated, stressing below 150/90 mmHg Valsartan H Unchanged NO the importance of adequate antihypertensive treatment (3). 6. If BP is not controlled or dry weight not attained in 30 days, con- The etiology of hypertension in dialysis patients is multi-fac- sider: Calcium channel blockers torial (Table 1). - 24-48 hours ABPM Amlodipine H Unchanged NO - increasing time of dialysis to facilitate removal of Table 1. Etiology of hypertension in dialysed patients (from ref. 4) fluid and attainment of dry weight _________________________________________________ Diltiazem H Unchanged NO Risk of conduction disturbance - discontinuing sodium modelling Felodipine H Unchanged NO - sodium and volume excess due to diminished sodium excretory - increasing the dose or number of antihypertensives capacity of kidney 7. If BP remains uncontrolled, consider: Isradipine H Unchanged NO - activation of the renin-angiotensin-aldosteron system - evaluating for secondary forms of hypertension Lacidipine H Unchanged NO - increased activity of the sympathetic nervous system - peritoneal dialysis - increased endogenous vasoconstrictor (endothelin-1, Na-K- - bilateral nephrectomy (exceptional) Nicardipine H Unchanged NO _________________________________________________ ATPase inhibitors, adrenomedullin), and decreased vasodilator Nifedipine H Unchanged NO (nitric oxide, prostaglandins) compounds Nitrendipine H Unchanged NO - frequent administration of erythropoietin Non-pharmacological treatment of hypertension in dialysed - increased intracellular calcium content, induced by parathyroid patients (Table 3) "50-75% Active metabolites Negative inotropic and dro- Verapamil H NO hormone excess Control of plasma volume can either normalize the blood pressure or accumulation" motropic effects - calcification of arterial tree, arterial stiffness help normalize blood pressure in dialysed patients. Multiple clinical Vasodilators - pre-existent hypertension definitions of stable “dry weight” have been advanced: - nocturnal hypoxemia, frequent sleep apnea - either the blood pressure has normalized or symptoms of hyperv- Smaller doses or slow inf. To _________________________________________________ Diazoxide R (H) Unchanged YES avoid decreasing of BP and of olemia disappear (not merely the absence of edema); protein binding - after dialysis seated blood pressure is optimal, and symptomatic Blood pressure measurement in dialysis patients orthostatic hypotension and clinical signs of fluid overload are not Induction of lupus-like syn- Pre- or post-dialysis blood pressure measurements in patients with present; Hydralazine H (NR) Dosing interval prolonged NO drome. Prolonged activity in hemodialysis may be misleading for the diagnosis of hypertension. - at the end of dialysis patients remains normotensive until the next slow acetylators The pre-dialysis systolic blood pressure may overestimate while the dialysis without antihypertensive medication. Minoxidil H Unchanged YES Active metabolites accumulation post-dialysis systolic blood pressure may underestimate the mean Some factors may limit fluid removal by predisposing to "Accumulation of thyocyanate. inter-dialytic systolic blood pressure by 10 mmHg; the mean systolic episodes of hypotension during hemodialysis treatment, as hypoten- Nitroprusside NR Titrate by blood pressure YES Thyocyanate is dialysable" blood pressure by 7 mmHg (5). sion is one of the important cardiovascular risk factors. Limiting control The ambulatory pressure monitoring (ABPM) appears to be of volume overload in dialysis patients has been denoted as lag phe- R=renal elimination, H=hepatic elimination, NR=non-renal elimination reproducible and it has shown that blood pressure is frequently high nomenon. pre-dialysis state, it falls immediately after dialysis, and then it gradu- To avoid large inter-dialytic weight gains, patients should References ally increases during the inter-dialytic period. ABPM may be useful in restrict salt intake (750 to 1000 mg of sodium/day). This also decreas- 1. Rahman M, Smith MC. Hypertension in hemodialysis patients. Current Hypertension Reports 10. Butt G, Winchester JF, Wilcox CS. Management of hypertension in patients receiving dialysis ther- determining “systolic blood pressure load” which is an important factor es thirst (an important factor of patient compliance). A fixed low 2001; 3: 496-502. apy. In Therapy of Nephrology and Hypertension. A companion to Brenner and Rector’s The in the development of left ventricular hypertrophy. Pre-dialysis blood dialysate sodium concentration with combination of dietary salt restric- 2. Kalantar-Zadeh K, Block G, Humphreys MH et al. Reverse epidemiology of cardiovascular risk fac- Kidney ed. by HR Brady, CS Wilcox., W.B. Saunders Company, Philadelphia, USA, 1999. tors in maintenance dialysis patients. Kidney Int 2003; 63: 793-808. 11. Jacobs C. Medical management of the dialysis patients. In Oxford Textbook of Clinical pressure correlates better with left ventricular hypertrophy than post- tion, or a programmed decrease in sodium dialysate concentration 3. Salem MM, Bower J. Hypertension int he hemodialysis population: any relation to one-year sur- Nephrology. Vol.3. Ed. By Davison AM, Cameron JS, Grünfeld J-P, Kerr DNS, Ritz E, Winearls G., dialysis blood pressure measurement (6). The dialyzed patients usu- (from 155 to 135 meq/L) may result in smaller doses of antihyperten- vival? Am J Kidney Dis 1996; 28: 737-40. Oxford Medical Publications, 1998. pp 2089-111. 4. Henrich WL, Mailloux LU. Hypertension in dialysis patients. Rose B. UpToDate online 11.3, 2004, 12. Renal Parenchymal Hypertension. Blood pressure in Chronic Dialysis Patients. In NM Kaplan: ally lose the diurnal variation in blood pressure and consequently sive drugs to control blood pressure. http://www.uptodate.com Kaplan’s Clinical Hypertension, Lipincott Williams & Wilkins, Philadelphia, USA, 2002. these patients develop nocturnal hypertension. The long, slow hemodialysis treatment (eight hours, and 5. Luik AJ, Kooman JP, Leunissen ML. Hypertension in hemodialysis patients: Is it only hyper- 13. London G, Marchais S, Guerin AP. Blood pressure control in chronic hemodialysis patients. In volaemia? Nephrol Dial Transplant 1997; 12: 1557-60. Jacobs C, Kjellstrand CM, Koch KM, Winchester JF: Replacement of renal function by dialysis, Home blood pressure measurement, an increasingly popu- three times a week) is associated with the maintenance of normoten- 6. Conion PJ, Walshe JJ, Heinle SK et al. Predialysis systolic blood pressure correlates strongly with Kluwer Academic Publishers, Dordrecht, Netherlands, 1996. pp 966-989. lar method, may be useful to estimate the blood pressure control also sion without medications in almost all patients, as this decreases affer- mean 24-hour systolic blood
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